Killing me softly

I was talking with my colleagues the other day about the new Washington State Initiative (dubbed I-1000 on this past November’s ballot)—the Washington Death with Dignity Act, usually referred to as physician-assisted suicide. The act went into effect on March 4th and for medical providers, it’s not just a personal consideration or a philosophical discussion. Everyone on the palliative care service has already been involved in patient-initiated discussions about it. I am a nurse practitioner and the act as written only allows physicians to prescribe lethal doses of medication to terminally ill patients who then must act on their own to decide if and when to take the medication and die a bit earlier than they might otherwise. I wish that the act included nurse practitioners, as I don’t believe that there are enough physicians in this State who are prepared to act in concert with this law. If I were allowed, I believe that I would be able to.

The act was passed by 60% of Washington State voters. Still, it allows for physicians, other health care providers, as well as institutions (hospitals, nursing homes, etc) to Opt Out. No one is forced to participate, either for personal, religious, political, or practical reasons; the act cannot force a single physician in the state to do the people’s bidding. If a hospital opts in, it does not guarantee than any of its staff will respond to requests by actually writing prescriptions. If a hospital opts out, it thereby forbids its physicians to provide life-ending medications when acting as an employee or staff and can terminate the staff privileges of doctors who do so.

I have a problem with this, as it will tend to isolate and make it all the more difficult for those who do want to act on behalf of patients who make the request. In Oregon, the only state in the US that has allowed physicians to prescribe lethal doses of barbiturates to terminally ill patients, only a handful of physicians have actually prescribed medications for this purpose. This is not to say that other health care providers abandoned patients, did not listen and empathize, or did not try their best to alleviate suffering. But at the end, most sent the patient to someone else to get what she came to them asking for. And the medical profession, including hospice and palliative care organizations, are playing it safe on this one. I’ve heard the arguments:

--We can always relieve pain and suffering, no one should have to resort to this act.

--The act potentially will exploit the most vulnerable among us.

--Most people who want to commit suicide are depressed and if treated for depression, would not choose to die.

I feel that these arguments are arrogant, even if well intentioned. Those of us working with chronically and terminally ill people at the last months of their lives know that we are not always able to make life bearable for those suffering. The Oregon experience has shown us that those asking for life-ending medications are well educated and resourceful people. The most common attribute among them is willfulness and the need for control in an unbearable situation.

Although the scope differs, the situation is otherwise similar for women seeking abortions. I worked in a women’s health center in Tallahassee Florida during the decade after abortion was legalized in by the Supreme Court in January 1973. My center eventually had to sue doctors in the local community who refused to provide abortions, but were harassing our doctors who traveled in from other communities. Tragically, a friend and colleague, Bayard Britton (John Bayard Britton MD) was murdered along with his bodyguard by the antiabortion activist Paul Hill in Pensacola, Florida in 1994. Bayard was wearing a bullet-proof vest, he knew the risk he was taking, but he also knew that some doctors had to provide abortions if the law was to have any meaning to women. I also knew Dr. David Gunn, who was also murdered in Pensacola prior to Bayard’s murder. There were so few doctors at that time in the entire state that were willing to perform abortions, they were not hard to pick off.

My team is struggling with the issue. I don’t know if it is right or wrong to hasten death in this way and I don’t know if I will ever know. I have the sense that there is no way to make a moral issue out of how to best alleviate human suffering. I suppose it is because I will never truly understand human suffering that I am drawn to try to alleviate it. If you wish to use the concept of God and the idea of a reckoning after death, then I guess we will have to wait to know if living according to our best understanding of what is good, was good enough. We might find out that it is as wrong to kill and eat animals as it is to torture prisoners. At their best, ideas about life remain relative to our ability to understand them. As for me, I don’t believe in a God who wishes for us to suffer and judges us for doing what we can to help others.